Supervision Training for CMHC Internship Site Supervisors

1. Supervision Training for CMHC Internship Site Supervisors Counseling and Human Services Roosevelt University

2. Why is Supervision important? Macro View • Society maintains a relationship with our profession which allows us to self-regulate, as long as we insure that the welfare of clients is held above our own self interest. • As part of this self-regulation, the profession is charged with the responsibility of: • controlling who is admitted to practice (Gatekeeper) • establish standards for behavior • Discipline of incompetent or unethical members.

3. Why Is Supervision Important Micro View • To foster the supervisee’s professional development • A supportive and educational function with precise and concrete goals for the supervisee to accomplish. • Derived from combination of supervisor’s own theory or model, supervisee’s particular developmental needs and the supervisee’s expressed wishes. • To ensure client welfare • Serving a Restorative Function • Assist interns to understand burnout and compassion fatigue issues and learn appropriate self-care techniques.

4. Goals of RU Internship Program • By the time that Interns complete their 600 hours, they should be able to: • Demonstrate competence in ethical thinking and ethical practice. • Demonstrate awareness of the influence of culture, race, gender and sexual orientation on the therapeutic process, therapeutic relationship, problem formation, maintenance, and resolution. • Demonstrate mastery of basic counseling skills. • Articulate a coherent theory of change and theory of clinical practice. • Demonstrate their personal theory through consistent case conceptualization, case presentations and audio/video case demonstrations.

5. Defining Supervision • Association for Counselor Education and Supervision (ACES) • . . . Involves facilitating the counselor’s personal and professional development as well as promoting counselor competencies for the welfare of the client. Supervisors oversee the counselor’s work through a set of activities that include consultation, counseling (if provided for by one’s model of supervision), training, instruction, and evaluation. • Supervision is a hierarchical and evaluative process. • It is also a collaborative and mentor relationship.

6. Intern Comments When Asked What Constitutes Good Supervision. • Support, Trust, Safety • Respectful • Nonjudgmental challenge • Praise for job well done • Constructive criticism • Time, Attention, Concern • Consistency & Accessibility • Allowed intern to be real and to voice concerns and frustrations. • Good clinical skills • Understanding of ethics & legal aspects. • Flexibility (able to move from one theoretical viewpoint to another) • Good understanding of diversity issues, special populations, etc. • Able to maintain a “big picture” view of the relationship • Collegial relationship

7. Intern Comments When Asked What Constitutes Difficult Supervision. • Cynicism and Burnout (not just in the supervisor, but in experienced staff. Supervisor must process this information with the intern!) • Rigidity & Inconsistency • See intern as just another employee (thrown to the wolves!) • Lack of adequate attention to skill development. • Believe that supervisees will acquire or catch needed skills by being exposed to others who are doing it. - “Germ Theory” • This is the concern with the frequent practice of shadowing, without adequate discussion of what is actually taking place and why it is taking place.

8. Conceptual Model of SupervisionBernard & Goodyear, (2009)

9. Credentialing Supervisors • In the past supervision was carried out by senior members of the profession. Today, supervision has become a sub-specialty within the counseling profession Professional. • Organizations like AAMFT have included special supervisor designations for many years - Approved Supervisor • Many state licensing boards now require higher level of credentialing in order to supervise post-masters level interns. • Supervisors must meet certain education and experiential requirements.

10. Credentialing Supervisors • No uniformity in credentialing across states. • General Requirements of State Licensure Boards: • Graduate Degree from Accredited Academic Institution or the Equivalent • Licensure within a specific professional discipline (2 or 3 years minimum years of licensed practice, with 2 or 3 years of pre-licensure clinical experience) • Specific Training in Supervision • Completion of a graduate level supervision class • Clinical Supervisors Course approved by a professional organization • CEU course work in clinical supervision and other areas of counselor development (Assessment & Evaluation, Ethics, Professional Development, etc. • Attestation of having thorough knowledge of supervisees practice activities, such as record keeping, fiscal management, ethics, etc.

11. Supervision Using Supervisee Self-Report • The grandfather of all supervision and still commonly used. • It is a very difficult form of supervision to perform well. • It is at it’s best when supervising more experienced students. • Muslin, et al. (1981) found that 50% of the important issues evident in videotapes of therapy sessions of psychiatric trainees were not reported in supervision. • Some degree of distortion characterized 50% of supervisee’s self-report. • Inexperienced therapists have a hard time comprehending the problems of clients. With self-report alone, supervisors are unable to actually observe trainee’s actions as they are taking place.

12. Supervision Using Supervisee Self-Report Self-Report • As a supervision strategy, it is only as good as the observational and conceptual abilities of the supervisee and the seasoned insightfulness of the supervisor. • Rogers & McDonald (1995) found that when supervisors used more direct methods of supervision they evaluated their supervisees as less prepared for the job than when they used self-report. • Anderson (2000) subjects far more likely to consider self-report as representing their worst supervision experiences than their best supervision experience.

13. Supervision Using Audiotape/Videotape • A picture is worth a thousand words!!! • During practicum and internship, RU requests either audiotaping or videotaping of sessions. • If at all possible, it would be optimal if site supervisors could review tapes with interns during individual supervision. • This allows supervisor to get a more accurate overview of supervisee’s ability. • Tape review allows the supervisor to: • Highlight the most productive parts of the session • Highlight the most important parts of the session • Highlight parts of the session where the student is struggling. • Discuss case conceptualization, theoretical development, etc.

14. Supervision Using Audiotape/Videotape • More experienced supervisees should be instructed to listen to tapes and select specific sections to be reviewed. • Transcribing tapes is a valuable lesson for students. • In this case the supervisee should be prepared to: • State the reason for selecting this part of the session for discussion in supervision. • Briefly state what transpired up to that point. • Explain what he or she was trying to accomplish at that point in the session. • Clearly state the specific help desired from the supervisor.

15. Integrated Developmental Model (Stoltenberg, McNeil & Delworth, 1998) • Domains – representative categories of knowledge central to becoming a counselor • Intervention skills competence: The ability to implement therapeutic interventions with assuredness • Assessment techniques: the ability to utilize assessment protocols and devices with assuredness • Interpersonal assessment: the ability to theoretically conceptualize a client’s interpersonal dynamics • Client conceptualization: the ability to organize client data into a meaningful diagnostic understanding upon which to base clinical treatment

16. Integrated Developmental Model (Stoltenberg,McNeil & Delworth, 1998) • Domains – Continued • Individual differences: the ability to include the influences of diversity and difference into the understanding of an individual client • Theoretical orientation: the ability to utilize and integrate different clinical theories and approaches • Treatment Plans and Goals: the ability to contract for change with a client and to effectively intervene to achieve therapeutic progress • Professional ethics: the ability to coordinate professional and personal ethics with standards of practice.

17. Integrated Developmental Model (Stoltenberg,McNeil & Delworth, 1998) • Integrated Development Model • 3 overriding structures that provide markers in assessing professional growth. • Self-Other Awareness • Where the student is in terms of self-preoccupation, awareness of the client’s world, and enlightened self-awareness • Motivation • Reflects the supervisee’s interest, investment, and effort expended in clinical training and practice. • Autonomy • Reflects the degree of independence that the supervisee is manifesting.

18. Integrated Developmental Model (Stoltenberg,McNeil & Delworth, 1998) • Integrated Development Model • Level 1. • Supervisees have limited training, or at least limited experience in the specific domain in which they are being supervised. • Motivation – Both motivation and anxiety are high; focused on acquiring skills. Want to know the correct or best approach with clients. • Autonomy – Dependent on supervisor,. Needs structure, positive feedback, and little direct confrontation. • Awareness – High self-focus, but with limited self-awareness; apprehensive about evaluation.

19. Integrated Developmental Model (Stoltenberg, McNeil & Delworth, 1998) • Integrated Development Model • Level 2 • Supervisees making the transition from being highly dependent, imitative, and unaware in responding to a highly structured, supportive, and largely instructional supervisory environment. Usually after 2 or 3 semesters. • Motivation – Fluctuating as the supervisee vacillates between being very confident to unconfident and confused. • Autonomy – Although functioning more independently, he/she experiences conflict between autonomy and dependency, much as an adolescent. This can manifest as pronounced resistance to the supervisor. • Awareness – Greater ability to focus on and empathize with client. Balance still an issue. Problem can be veering into confusion and enmeshment with the client.

20. Integrated Developmental Model (Stoltenberg, McNeil & Delworth, 1998) • Integrated Development Model • Level 3 • Supervisee focusing more on a personalized approach to practice and on using and understanding of “self” in therapy. • Motivation – Consistent; occasional doubts about one’s effectiveness will occur, but without being immobilizing. • Autonomy – A solid belief in one’s own professional judgment developed as the supervisee moves into independent practice. Supervision tends to be collegial as differences between supervisor and supervisee expertise diminish. • Awareness – Supervisees return to being self-aware, but with a very different quality than at Level 1. Able to remain focused on the client while also stepping back to attend to their own personal reactions to the client and then to use this in decision making about the client.

21. Integrated Developmental Model (Stoltenberg,McNeil & Delworth, 1998) • Integrated Development Model • Level 3i (Integrated) • Occurs as supervisee reaches Level 3 across multiple domains • Including treatment, assessment, & case conceptualization. • Characterized by a personalized approach to professional practice across domains and the ability to move easily across them. • Supervisee has strong awareness of his or her strengths and weaknesses.

22. Discrimination Model (Bernard, 1997) • Developed by Janine Bernard in 1970s as a teaching tool. • A-theoretical and A-cultural model for training novice therapists. • It is parsimonious and versatile. • Implies that the supervisor will tailor their responses to the particular needs of the supervisee. • Supervisor roles and foci will change throughout each supervision session. • Three supervisory roles Three Focus Areas • Teacher - Intervention skills • Counselor - Conceptualization skills • Consultant - Personalization skills

23. Discrimination Model (Bernard, 1997) Supervision Foci: Intervention skills • Focus on what the counselor does in the therapy session, from start to finish. Focus on what is observable. • Focus on implementation skills, rather than on the planning or anticipation of them. • May include: • The ability to open an interview smoothly • Competent use of reflections, probes, restatements, summaries, and interpretations • Understanding of nonverbal communication to enhance verbal communication • Achieving interview closure.

24. Discrimination Model (Bernard, 1997) Supervision Foci: Conceptualization skills • Addresses a counselors ability to sort out the essential information presented by the client to identify themes and to develop a working understanding of the client’s life situation. • Reflects on deliberate thinking and case analysis by trainees. • It is important to note that a counselor's philosophy or theory of counseling directly influences how he or she understands and diagnoses the client’s concerns. • May include: • Understand what clients are saying • Identify themes in clients’ messages • Recognize appropriate and inappropriate goals for clients • Choose strategies appropriate to clients’ expressed goals • Recognize event subtle client improvements.

25. Discrimination Model (Barnard, 1997) Supervision Foci: Personalization Skills • Involves trainee use of aspects of self as they relate to the counseling experience. • May include: • Comfort in assuming some authority in the counseling relationship and taking responsibility for their specialized knowledge and skills. • Hearing challenges by clients and feedback from supervisors without becoming overly defensive • Comfort with their own feelings, values, and attitudes as well a those of their clients • Fundamental respect for their clients.

26. Discrimination Model (Bernard, 1997)

27. Legal and Ethical IssuesinSupervision

28. Ethical Principles • We have all had ethics classes and we are all aware of the principles stated below: • Autonomy – patients have the right to be self directed. • Beneficence – we are to work for the health & welfare of out client. • Justice – fair and equal treatment • Nonmalfeasance – refrain from intentionally inflicting harm • Fidelity – keeping promises in the client/therapist relationship • Unfortunately, therapists, interns, and supervisors sometimes act in ways that violate these principles and initiate legal response. • Whether the actions are intentional or unintentional, the liability is no less significant. • Ignorance is clearly not a mitigating circumstance!

29. Ethical and Legal Issues • Ethics and legal matters are often related, but each has a distinct purpose. • Ethical standards are a call to ethical excellence. • Generally broad in nature and open to interpretation. • They are a statement from the profession to the general public regarding what we stand for. • The law is specific in nature. • Not focused on excellence, but on minimal standards. • For a professional to be considered liable, it is generally accepted that he/she acted outside the bounds of accepted practice.

30. Ethical Issues for Clinical Supervision • Due Process • A legal term for procedure that ensures that notice and hearing must be given before an important right can be removed. • Substantive Due Process – procedures that govern a training program must be applied consistently and fairly. • Procedural Due Process – has to do with the rights of the individual to be notified. • Supervisee-student should be apprised of the academic and performance requirements and program regulations, receive notice of any deficiencies, be evaluated regularly, and have an opportunity be heard if their deficiencies have let to a change in status. • Most supervision literature focuses on procedural due-process!

31. Ethical Issues for Clinical Supervision • Due Process • When full due process procedures are followed: • Supervisee is guaranteed a respectful review of a situation and the expert opinions of professionals, in addition to that of the person initiating the complaint. • By following this procedure, the institution is equally protected form the accusation that its action was capricious or arbitrary.

32. Ethical Issues for Clinical Supervision • Informed Consent • Best defense against a charge of malpractice for practitioners. • For supervisors, there are 3 levels of responsibility: • Supervisor must determine that clients have been informed by the supervisee regarding the parameters of therapy. • Supervisor must also be sure that clients are aware of the parameters of supervision that will affect them. • Supervisor must provide the supervisee with the opportunity for informed consent.

33. Ethical Issues for Clinical Supervision • Informed Consent with Clients • It is essential that clients understand and agree to the procedures of therapy prior to its beginning. • Factors that constitute necessary and sufficient informed consent: • Risks and benefits of treatment • Logistics of treatment, including length of sessions, costs, opportunities for telephone contact, etc. • Info on the type of counseling to be provided • What is expected of the client (homework, family involvement, etc.) • Preferred alternatives to the type of treatment being offered • Risks of receiving no treatment

34. Ethical Issues for Clinical Supervision • Informed Consent Regarding Supervision • Client must also be aware of supervision procedures. • Will the sessions be taped? • Who will be watching? • How intrusive is the supervision? • Are their emergency procedures? Is therapist available via telephone? • Supervisees place themselves in a position to be sued if they don’t tell the family that they are going to discuss the case with a supervisor. • It is vitally important that a student not mislead the client regarding the fact that they are in training!!! • May be exposed to charges of fraud, misrepresentation, deceit, etc.

35. Ethical Issues for Clinical Supervision • Informed consent with trainees • Trainees must be informed of evaluative criteria. • Must be informed of the conditions that dictate their success or advancement. • Must also be clear what their responsibilities are and what the supervisors responsibilities are. • If there is a possibility that personal counseling will be recommended for any trainees in a given program, all trainees should be cognizant of this practice upon entering the program. • Supervisees should be included in the choice of supervisors, the form of supervision, the expectations of the supervisor, the theoretical orientation of the supervisor.

36. Ethical Issues for Clinical Supervision • Dual Relationships • Most flagrant type of dual relationships are sexual relationships between therapists and clients. • Sexual exploitation of a client is grounds for the automatic revocation of licensure or certification. • It is the responsibility of the supervisor to be certain that supervisees understand the definition of a dual relationship. • Problematic dual relationships with supervisees can include intimate relationships, therapeutic relationships, work relationships, and social relationships. • What makes a dual relationship unethical is: • The likelihood that it will impair the supervisor’s judgment • The risk to the supervisee of exploitation

37. Ethical Issues for Clinical Supervision • Dual Relationships • Preventing Supervisee Ethical Transgressions. • Preventive education and honest discussion between supervisors and trainees about the possibility, if not the probability, of occasional sexual attraction to clients, supervisees, or supervisors. • It is important that the supervisor accept responsibility for raising the topic. • “Ethical supervision is embedded in a clearly articulated supervisor-student relationship that monitors misuse of power and boundary crossings, yet is capable of deeply personal discourse” (Bridges, 1999)

38. Ethical Issues for Clinical Supervision • Dual Relationships between Supervisor and Supervisee • Intimate Romantic Relationships • Sexual relationships that grow our of supervisory relationships, in which both parties experience positive, caring feelings are relatively common. • If both are adults and both are consenting, then is is difficult to label as inappropriate. • The issue is how to prevent it from becoming unethical. • Should sever the supervisory relationship.

39. Ethical Issues for Clinical Supervision • Confidentiality • Confidentiality violations are the most common violations for trainees. • Supervisor must be sure that trainee keeps confidential all client information except for purposes of supervision. • In group supervision the supervisor must be especially careful with the identify of patients being discussed in front of multiple trainees. • Must be sure that all trainees maintain information overheard in supervision meetings as confidential. • Finally, it is the responsibility of the supervisor to maintain the confidentiality of the trainees, when they have shared confidential information.

40. Ethical Issues for Clinical Supervision • Confidentiality, Privacy, & Privileged Communication • Confidentiality involves professional ethics rather than any legalism and indicates an explicit promise to reveal nothing about the client without consent. • Privacy is the other side of confidentiality. It is the client’s right not to have private information divulged without informed consent, including information divulged in therapy. • Privileged communication is a legal concept and is the result of state statute. Refers to the right not to have the confidential communication used in open court without their consent. • Although all privileged communication is confidential, not all confidential information is privileged.

41. Legal Ramifications of Clinical Supervision • Malpractice • The difference between a claim of an ethical violation and a claim of malpractice is determined whether the aggrieved chose to bring the complaint to a regulatory body or civil court. • There are far more claims to regulatory bodies than there are lawsuits. • Reasons being the cost of litigation is prohibitive. • Legal complaints are restricted by tort law. Defendant must be able to prove that the negligence claimed resulted in harm. Most can’t meet this burden of truth. • Must also prove that the intention of the therapist is to cause harm.

42. Legal Ramifications of Clinical Supervision • Malpractice • 3 elements must be proved for a plaintiff to succeed in a malpractice claim. • A fiduciary relationship with the therapist must have been established. Within supervision, this means that the supervisor is working in the best interest of the supervisee and the supervisee’s clients hand not in his or her own interest. • Therapist’s or supervisor’s conduct must have been improper or negligent and fallen below standards. • The client or supervisee must have suffered harm or injury • A causal relationship must be established between the injury and the negligence or improper conduct.

43. Legal Ramifications of Clinical Supervision • Duty to Warn – Tarasoff v. Regents of the University of California • Example of a legal precedent becoming an influence on ethical codes. • Now a legal standard for all mental health professionals and has become a law in many states. • It is imperative for supervisors to inform supervisees of conditions under which it would be appropriate to implement the duty to warn. For the protection of intended victims. • Two issues are embedded: • Assessing the level of dangerousness of the client • Identification of a potential victims. • Legal experts seem to lean in favor of client privilege unless there is clear evidence that a client is immediately dangerous and there is an identifiable victim.

44. Supervisor Liability • Direct Liability - When the actions of the supervisor are the cause of harm. • failure to complete supervision adequately, • suggests an intervention that is determined to be harmful. • Very rare for supervisors • Vicarious Liability - When the supervisor is held liable for the actions of the supervisee or by virtue of the relationship with the supervisee. • Is the supervisee working under the direct control of the supervisor? • Was the supervisee working within the defined scope of tasks permitted by the supervisor? • Does the supervisor have the power to control and direct the supervisee’s work?

45. Roosevelt UniversitySupervisor Orientation • Roosevelt University Counseling and Human Services program provides orientation information for site supervisors when our students begin their practicum and internship experience.

46. Questions? • If you have any questions, please feel free to contact the university instructor or Field Placement Liaison for your student’s campus: • Chicago: Dr. Kristina Peterson, kpeterson@roosevelt.edu; 312-853-4779 • Schaumburg: Dr. Bruce Dykeman, bdykeman@roosevelt.edu; 847-619-8822